Summer’s Water Woes

As the mercury peaks in August, a few pediatric ailments have their moment in the sun.

‘Dry Drowning’No, it’s not a thing, but you’ll need to educate worried parents.

The patient in bed two is an otherwise healthy four-year-old who is running around the room while you interview his worried mother. He has had about 10 hours of vomiting and subjective fever. He has vomited a total of five times. His vital signs are normal. The mother says she typically would not have brought him to the ED for this but he was at the pool yesterday, so she is concerned about dry drowning and wants him checked.

Dry drowning? Where is this coming from? In June, CNN reported a child that supposedly died of dry drowning in Texas. According to the story, a four-year-old boy was playing in the water and was knocked down by a wave. He went under briefly and was picked up by a family friend. He played the rest of the day, but the next night, more than 24 hours later, developed vomiting and diarrhea. The patient was managed at home and the symptoms continued for several days. Then one night he woke up complaining of shoulder pain. Sometime after that he stopped breathing. He was taken to the ED where resuscitation attempts were unsuccessful. Per CNN, water was found in his lungs and around his heart and the family was told he died of ‘dry drowning’ or ‘secondary drowning.’ This story was widely reported. Parents Magazine even published “Dry Drowning: Know the signs.” You have had a run of worried parents ever since. Should you be worried too?

First of all, some definitional problems. Terms such as “dry drowning,” “near drowning” and “secondary drowning” are confusing and imprecise. The Utstein guidelines define drowning as “a process resulting in primary respiratory impairment from submersion or immersion in a liquid medium.” No “dry,” “delayed,” or “secondary” terminology.

In 1996, a study asked: Do all nonfatal drowning patients require inpatient admission? Almost all the children who were without symptoms in the ED continued to have no symptoms eight hours after the submersion event. Of the patients who had initially had symptoms, 57% also asymptomatic eight hours after the event. By 18 hours after the submersion episode, all the initially asymptomatic patients, and 72% of the patients who initially had symptoms were back to normal. Based on this study, the authors made the following recommendations:

Admit all ill, symptomatic children after a submersion event.

Observe all others in the ED for 6-8 hours.

Asymptomatic children who do not develop any symptoms in the ED in the 6-8 hour observation period can go home.

Children with mild symptoms who return to normal in the 6-8 hour window can also go home, with follow-up in 24 hours.

Similar studies of children and adults have also shown that patients who ultimately develop symptoms from nonfatal drowning will do so by 8 hours after the event.Symptoms to watch for include mainly respiratory symptoms such as cough, retractions, wheezing, crackles or signs of CNS depression such as sleepiness, lethargy. Vomiting can also be seen.

What did this poor child from Texas die of? He had symptoms develop more than 24 hours after the event, including diarrhea as well as vomiting. This sounds more like a virus than anything else. Fluid in the lungs can occur from drowning but fluid around the heart sounds more like a viral myocarditis. His brief submersion in water certainly had nothing to do with his unfortunate outcome. I could find no case report of a patient without symptoms for 24 hours developing symptoms from a submersion episode.

So reassure these worried parents. If their child has no symptoms within eight hours of a submersion event, then whatever comes later is due to something else.

CryptosporidiosisLooks like your next patient picked up an infection at the pool.

Your next patient is a seven-year-old girl with diarrhea. She was well until three days ago when she developed watery diarrhea and some crampy abdominal pain. She has nausea but no vomiting, decreased appetite and low-grade fever. Her fluid intake is good and her urine output is normal. She is otherwise a healthy child. She has had no ill contacts. Her family was on vacation two weeks ago and she swam in the hotel pool every day. She is an enthusiastic but clumsy swimmer and sometimes swallows water.

Her exam is unremarkable. She looks adequately hydrated. Mom wants to know if it could be something in the pool water.

The answer is yes. Her clinical picture could easily fit with cryptosporidium infection.

Cryptosporidium is a protozoan that causes a secretory diarrhea. It is spread by contact with an infected person or animal or infected food or water. In immunocompetent patients it generally causes mild disease that resolves without treatment in 10-14 days. Besides diarrhea, symptoms can include malaise, anorexia, crampy abdominal pain and mild fever. The diagnosis can be made by microscopy, PCR or enzyme assays. If symptoms are severe or last longer than 14 days, treatment with nitazoxanide can be initiated. In patients with HIV or other immunocompromised states, symptoms can be severe.

Antimicrobial prophylaxis is not generally administered and asymptomatic contacts should just be counseled about good hand washing. Infected patients should not go back in the pool for two weeks after recovery in order to avoid spreading the infection.

You send a stool for PCR, and the test comes back positive. You phone the mother who reports that the child is already improving. You advise plenty of fluids and staying out of the pool for two weeks and reassure the mother that she is going to be fine.

An eight-year-old boy comes in for a rash. He was at the beach last week in North Carolina. Getting out of the water he felt some burning underneath his bathing suit. Later, after showering outside in his suit, he developed an itchy rash in his lower abdomen, groin and upper thighs. Over several hours he developed a low-grade fever, cramping abdominal pain and nausea, which improved over the next two days. He is here because the rash persists.

On exam, you see an active child in no distress. His vitals are normal. His exam is unremarkable until you check under his shorts. There he has red papules with some coalescence in an area corresponding to his bathing suit. These are most intense along his waistband.

So what is this and what should you do about it? Your patient’s history and exam are typical of seabather’s eruption. It is caused by larval forms of jellyfish, such as Linuche unguiculata and Edwardsiella lineata, found in seawater. The tiny larvae wash into the bathing suit and are trapped against the skin. When the swimmer gets out of the ocean and the water drains out of the suit, friction activates the nematocysts, or stinging mechanisms of the larvae, to release their toxin. Air-drying, toweling and exposure to freshwater from a pool or shower also trigger the nematocysts to discharge. Patients develop a pruritic rash with red papules and urticaria in the area covered by clothing, which can coalesce and are most intense in pressure points. Swimmers who wear tee-shirts or wet suits can develop the rash under these as well. Some patients develop mild systemic symptoms such as chills, fever, malaise, nausea and abdominal pain. The symptoms generally resolve in 1-2 weeks. It is important to note that the nematocysts can persist in clothing and continue to inject toxin if the clothes are re-worn.

Treatment is symptomatic. Use low-potency topical steroids and antihistamines for the itching and antipyretics for fever or pain. Bathing suits should be machine washed before being worn again.

1 Comment

Dear Amy, Thank you for this excellent article to help educate worried parents. I received in my mailbox from Medpage Today and I want your permission to republish in print and online, and in English and Spanish. Please let me know what will be my next step.

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